Brenda Mai

Cutaneous extramedullary hematopoiesis (CEH) is a rare manifestation of extramedullary hematopoiesis (EMH), a process typically associated with fetal development or myeloproliferative neoplasms. EMH most commonly involves the spleen, liver, and lymph nodes, with CEH being exceedingly rare in chronic myeloid leukemia (CML). Here, we present a 34‐year‐old Hispanic male with multiple bilateral lower extremity lesions, right buttock and leg pain, fatigue, and splenomegaly, who was found to have chronic‐phase CML. Punch biopsy of one of the skin lesions demonstrated dermal infiltration by maturing hematopoietic elements, including granulocytes, megakaryocytes, and erythroid precursors, with fluorescence in situ hybridization (FISH) testing confirming a neoplastic extramedullary hematopoietic infiltrate with the presence of BCR::ABL1 fusion. Initial treatment included hydroxyurea and dasatinib; however, after chronic‐phase CML was confirmed, therapy was transitioned to imatinib, resulting in resolution of B symptoms, normalization of WBC counts, and reduced leg swelling. This case underscores the importance of distinguishing CEH from aggressive disease states, such as blast‐phase CML or myeloid sarcoma, through comprehensive histopathological and immunohistochemical analysis.

BACKGROUND Acute coronary syndrome is the most common cause of death in the United States. Successful intervention often requires a multi-therapeutic approach, including percutaneous coronary intervention (PCI) and antiplatelet agents such as ticagrelor. However, the use of antiplatelet agents can cause life-threatening bleeding, particularly during emergency procedures. Therapeutic plasma exchange (TPE) is a procedure that selectively removes the patient's plasma to eliminate harmful substances. Here, we present 2 cases of novel TPE implementation in the setting of uncontrolled ticagrelor-induced bleeding. CASE REPORT Our first case was a 52-year-old man who presented with ST-elevation myocardial infarction. He underwent emergency percutaneous coronary intervention and was started on dual antiplatelet therapy (aspirin 81 mg/day, and ticagrelor 90 mg twice daily). A post-infarction ventricular septal defect required emergency surgical repair. After the surgery, uncontrolled bleeding persisted despite all conventional treatment methods. Following TPE, the bleeding was controlled, hemostasis was achieved, and platelet function was increased within days. Our second case was a 66-year-old man who received single doses of ticagrelor (180 mg) and eptifibatide (180 mcg/kg) during an attempted PCI. After complication by left main coronary artery dissection, emergency 2-vessel coronary artery bypass surgery was performed. In the immediate postoperative period, TPE was performed for persistent uncontrolled bleeding. Platelet reactivity increased immediately following the procedure; bleeding was stabilized, and no further blood products were required after postoperative day 1. CONCLUSIONS TPE may be an effective novel option for emergency removal of circulating ticagrelor in refractory bleeding cases.

Primary effusion lymphoma (PEL) is a rare type of large B-cell lymphoma associated with human herpesvirus 8 (HHV8) infection. Patients with PEL usually present with an effusion, but occasionally with an extracavitary mass. In this study, we reported a cohort of 70 patients with PEL: 67 men and 3 women with a median age of 46 years (range 26–91). Of these, 56 (80%) patients had human immunodeficiency virus (HIV) infection, eight were HIV-negative, and six had unknown HIV status. Nineteen (27%) patients had Kaposi sarcoma. Thirty-five (50%) patients presented with effusion only, 27 (39%) had an extracavitary mass or masses only, and eight (11%) had both effusion and extracavitary disease. The lymphoma cells showed plasmablastic, immunoblastic, or anaplastic morphology. All 70 (100%) cases were positive for HHV8. Compared with effusion-only PEL, patients with extracavitary-only PEL were younger (median age, 42 vs. 52 years, p = 0.001), more likely to be HIV-positive (88.9% vs. 68.6%, p = 0.06) and EBV-positive (76.9% vs. 51.9%, p = 0.06), and less often positive for CD45 (69.2% vs. 96.2%, p = 0.01), EMA (26.7% vs. 100%, p = 0.0005), and CD30 (60% vs. 81.5%, p = 0.09). Of 52 (50%) patients with clinical follow-up, 26 died after a median follow-up time of 40.0 months (range 0–96), and the median overall survival was 42.5 months. The median OS for patients with effusion-only and with extracavitary-only PEL were 30.0 and 37.9 months, respectively (p = 0.34), and patients with extracavitary-only PEL had a lower mortality rate at the time of last follow-up (35% vs. 61.5%, p = 0.07). The median OS for HIV-positive and HIV-negative patients were 42.5 and 6.8 months, respectively (p = 0.57), and they had a similar mortality rate of 50% at last follow-up. In conclusion, patients presenting with effusion-only versus extracavitary-only disease are associated with different clinicopathologic features. PEL is an aggressive lymphoma with a poor prognosis, regardless of extracavitary presentation or HIV status.

Mucosal-associated lymphoid tissue (MALT) lymphoma can typically be identified as a mass lesion or nodularity endoscopically and macroscopically. We report an incidental finding of a Helicobacter pylori gastric mucosal-associated lymphoid tissue (MALT) lymphoma in a sleeve gastrectomy specimen with no gross examination findings.

There are approximately 800 new cases of acute promyelocytic leukemia (APL) in the United States every year. APL is rarely observed in pediatric populations, and accounts for less than 5-10% of all pediatric cases of acute myeloid leukemia (AML). APL typically presents with symptoms related to the pancytopenia such as fatigue due to anemia, bleeding and bruising secondary to thrombocytopenia, and infections attributed to a lack of functioning leukocytes. The presentation of APL in the central nervous system (CNS) is a rare phenomenon. In addition, APL has a dismal prognosis when found in the CNS. In this case study, we describe a unique presentation of pediatric APL with cryptic insertion of the promyelocytic leukemia (PML)-retinoic acid receptor-alpha (RARA) fusion protein with a surprisingly excellent recovery.